Carb Counting. Is it Still Needed with New Insulin Dosing Technologies?


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Talking about carb counting may bring to mind an image of numbers and calculations that initially seem impossible to us. However, carb counting is one of the most useful strategies for diabetes management and during #ADA2021 we had the opportunity to learn more about it.

Dr. Becky Sulik, Director of Education at Rocky Mountain Diabetes & Osteoporosis Center and member of the Board of Directors of NCBDE talked about the perspective from the real world of carb counting for decision making especially when insulin is taken for meals. Before going to that point, let’s remember the evolution that the carb count has had from the “starvation diet” where all carbs were eliminated, the same as “the diet” before the arrival of insulin to the present day where the bolus calculators make the process easier. In fact, we are waiting for new artificial intelligence devices with even more advanced algorithms that will facilitate many of these processes with their modern algorithms.

Necessary Transferable Skills

In order to apply carb counting, certain skills are needed, especially when it comes to “advanced carb counting”, among these are found:

  • Being able to identify foods that contain carbohydrates.
  • Understand and evaluate the portion size.
  • Being able to estimate the grams of carbs that each portion of food has as well as the complete dish
  • Consider the necessary doses (bolus) before meals according to the blood glucose that you have and the blood glucose goals
  • Be able to calculate the amount of insulin (bolus) according to the previously individualized ratio

All this can seem a bit complicated. However, carb counting has at least two very important benefits: First, it favors the decrease in the levels of Glycated Hemoglobin (A1c), and second, it improves the quality of life by being able to make eating more flexible.

As it can happen, carb counting also has some barriers among which are:

  • Errors in the labeling of some products can cause confusion and conflict in the size of the portions of some foods
  • Applying and learning carb counting requires time and previous knowledge
  • Forgetting to take basal insulin (for food intake)
  • Having distractions and interruptions that can cause confusion or a wrong carb count, or a wrong insulin ratio.

This results in an approximately 22 percent variability in the number of carbohydrates that are ingested and the amount of insulin that is taken is generally underestimated. In addition, errors in the estimates of insulin for food intake (bolus) are directly related to the size of the meal, when meals are bigger the mistakes are also bigger. These mistakes are related to the variability in blood glucose that is often seen in people with diabetes.

There is another situation that, fortunately for those of us who live with diabetes, is already being considered by some health professionals. It is the emotional burden and fatigue that can happen to those who do the carbohydrate count. For this, it is suggested to those who rely on carb counting to use tools such as telephone applications, bolus calculators, tools to measure and standardize measurements (cups, spoons, etc.) and try to simplify when possible.

Hence the relevance of a treatment where decisions are made but which focus on the needs of the patients. Thus, it is necessary to speak in terms of food that is familiar to that particular individual and it will also be necessary to monitor the risk of eating disorders avoiding the classification of food as “good” or “bad”.

Impact of Fats and Proteins on Blood Glucose

According to the American Diabetes Association, consider these guidelines:

  • When consuming foods that contain carbohydrates and that are high in fat and/or protein, insulin doses should not be based solely on carbohydrate counts.
  • An increase in insulin doses done with caution is recommended for foods high in fat or protein to avoid late hyperglycemia that can happen three hours or more after eating.
  • Dietary fat and protein in foods have an impact on both early and late forms of postprandial blood glucose (post-meal blood glucose).
  • It is necessary to make changes in the insulin doses as well as to consider the possibility of using a dual bolus for meals high in fat and protein.

Fat and protein have an impact on blood glucose levels because they also influence insulin secretion. In people, without diabetes, there is minimal impact on blood glucose levels. However, an important insulin response has been found in people with type 1 diabetes. If the insulin dose is not enough, these foods will cause hyperglycemia.

The fat or proteins separately with a food that contains carbohydrates can reduce the postprandial blood glucose peak shortly after the meal (two-three hours), they decrease the blood glucose peaks. However, they can cause late hyperglycemia (>three hours) so it is necessary to make an adjustment in the dose and the way in which insulin is taken when eating meals that are high in fat or protein.

There is still a lot of research and advances in the ratio of carbohydrates to insulin as well as other macronutrients, but technology is advancing and little by little advances have been made to avoid the need to carry out carb counting when it comes to low carbohydrate meals with a moderate protein and fat content. This means a decrease in fatigue and in the risk of burnout caused by strenuous blood glucose management in those living with diabetes.

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WRITTEN BY Eugenia Araiza, POSTED 06/28/21, UPDATED 10/10/22

Eugenia is a nutritionist and diabetes educator. She has been living with type 1 diabetes since 1995. In 2019, she started Healthy Diabetes, a project that includes educational resources to support and empower people living with diabetes. She is the author of the book Soy Diferente y me Gusta (I am Different and I Like It), which preaches about acceptance when living with diabetes. She recently co-authored a book called Había una vez una Diabetes (Once Upon a Time There was Diabetes) which addresses diabetes burnout in diabetes from a professional perspective and with a personal and unique twist. Eugenia is co-founder of Diabetes and Co, an online educational platform for the different types of diabetes. She is currently a project manager at Beyond Type 1.